Treatment of stage IVA hepatocellular carcinoma: should we reappraise the role of surgery?

HYPOTHESIS

A subset of patients with stage IVA hepatocellular carcinoma (HCC) and preserved liver function may benefit from hepatic resection.

DESIGN

Retrospective review of a prospectively collected database.

SETTING

An academic tertiary care hepatobiliary unit.

PATIENTS

Twenty patients who underwent surgical treatment for stage IVA HCC between July 1998 and October 2004 were identified from the database.

INTERVENTION

Intraoperative ablation of HCC nodules was combined with resection in 6 patients (30%) to increase resectability. Three patients also underwent resection of extrahepatic tumors. Five patients (25%) had macroscopic invasion of the portal vein and 2 patients (10%) underwent thrombectomy of the vena cava.

MAIN OUTCOME MEASURES

Intraoperative data, recurrence, and long-term survival rates were analyzed.

RESULTS

Postoperative mortality and morbidity were 5% and 30%, respectively. The median number of resected tumors per patient was 3, and the median diameter of the largest tumor was 60 mm. With a median follow-up of 23 months, 14 patients (70%) developed recurrence. Treatment of recurrence was possible in 10 patients and included transarterial chemoembolization in 7 patients (35%), of whom 2 (10%) had radiofrequency ablation first, and systemic chemotherapy in 3 patients (15%). Median survival time was 32 months, and the actuarial 1-, 3-, and 5-year survival rates were 73%, 56%, and 45%, respectively.

CONCLUSIONS

Long-term survival can be achieved using an aggressive surgical approach in select patients with advanced HCC. Patients with stage IVA HCC should be followed up by a multidisciplinary team because recurrence is common and sequential treatments may prolong survival.